Healthcare Provider Details

I. General information

NPI: 1629272695
Provider Name (Legal Business Name): GRANITE STATE PODIATRY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 HANOVER STREET
MANCHESTER NH
03104
US

IV. Provider business mailing address

424 HANOVER STREET
MANCHESTER NH
03104
US

V. Phone/Fax

Practice location:
  • Phone: 603-668-3509
  • Fax: 603-641-8442
Mailing address:
  • Phone: 603-668-3509
  • Fax: 603-641-8442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0139
License Number StateNH

VIII. Authorized Official

Name: ELLEN YUSE
Title or Position: OFFICE MANAGER
Credential:
Phone: 603-668-3509